The extensive blood supply to the stomach has historically made gastric ischemia an uncommon occurrence. In addition to minor and collateral arterial sources, which form a complex plexus to the stomach, there are 5 major direct arterial sources, including the right and left gastric, right and left gastroepiploic, and short gastric arteries.⁹ The gastric ulcer in this patient probably resulted from embolization of the short gastric arteries that branch off the splenic artery. The short gastric arteries supply the fundus and portions of the greater curvature of the stomach.

Few cases of gastric ulceration after splenectomy have been reported.^10,11 In a case of a bleeding gastric ulcer that had developed 2 weeks after preoperative splenic artery embolization and splenectomy for massive splenomegaly, surgical intervention was required to control the bleeding. The ulcer was located on the proximal greater curvature on the luminal side of a suture-ligated short gastric vessel.⁴

In another case of a 14-year-old boy with massive gastric bleeding 8 months after a splenectomy, emergent surgery revealed an abscess in the former splenic site that had eroded transmurally into the gastric lumen along the greater curvature.¹² A partial gastrectomy of the involved stomach was performed; the patient had a complete recovery several weeks later.

In the case presented here, right-sided heart failure was the most likely cause of the congestive splenomegaly. Splenectomy had been excluded because of the patient's underlying severe pulmonary hypertension. Histologic examination of biopsy specimens revealed no full-thickness gastric wall involvement or evidence of a gastric fistula or perforation from a splenic abscess. Thus, splenic artery embolization was determined to be the cause of this patient's large gastric ulcer.